Provider Demographics
NPI:1285034678
Name:QUEENS BLVD EXT CARE FACILITY MANAGEMENT LLC
Entity Type:Organization
Organization Name:QUEENS BLVD EXT CARE FACILITY MANAGEMENT LLC
Other - Org Name:QUEENS BLVD EXT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-205-0298
Mailing Address - Street 1:6111 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4965
Mailing Address - Country:US
Mailing Address - Phone:718-205-0298
Mailing Address - Fax:
Practice Address - Street 1:6111 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4965
Practice Address - Country:US
Practice Address - Phone:718-205-0298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703410N261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2996110Medicaid
NY335791Medicare PIN